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Office of Public and Intergovernmental Affairs

Remarks by Deputy Secretary Sloan Gibson

AMVETS 71st National Convention
Birmingham, Alabama
August 20, 2015

We still have work to do.

Veterans’ demand for care and benefits still exceeds VA’s capacity to meet that demand, and, as a result, Veterans wait too long.

We need to streamline the six different channels for care in the community that have evolved over the last 20 years into a single program that Veterans, private-sector providers, and VA staff can understand.

We have to work through the construction challenges resulting from poor decisions made years ago, improve our leasing processes to be more responsive to the needs of Veterans, and be better stewards of taxpayer dollars.

In IT, we must manage our way through technical debt accumulated over decades to build the technology platform needed for state-of-the-art care and service. . . . We’re running the largest healthcare organization in America with a 20-year-old financial management system, no integrated logistics management system, and a Veteran can’t easily go from one medical center to another and get a prescription filled.

We deliver hundreds of thousands of great outcomes to Veterans every day, but we lack the rigor in our systems and processes to ensure we replicate those outcomes every single time.

We have to change a culture where, too often, frontline staff are reluctant offer suggestions to improve day-to-day operations and where many still define success as following the rules rather than meeting the needs of the Veterans we serve.

And we still struggle with insufficient funding and little financial flexibility to meet the needs of Veterans. We’ll spend a billion dollars this year curing Veterans of Hepatitis C using drugs that weren’t even approved by the FDA when we first submitted our FY15 budget to Congress.

So we still have work to do—fundamental and comprehensive transformation.

Let’s take a minute to put this in context.

We have nine lines of business, and 11 million Veterans are registered, enrolled, or use at least one VA benefit or service.

We provided four million Veterans and survivors compensation for disability, totaling $58 billion last year, and assisted another 100,000 disabled Veterans with vocational rehabilitation and employment benefits.

We provide Post-9/11 GI Bill benefits to 1.4 million Veterans and family members.

We have a $126 billion home-loan guarantee portfolio with the lowest foreclosure rate in the industry.

VA is the Nation’s 10th largest insurance enterprise, with $1.3 trillion in coverage.

Our National Cemetery Administration (NCA) oversees 131 National Cemeteries. For the past decade, NCA’s been ranked the top customer-service organization in the Nation—public or private—by the American Customer Satisfaction Index.

With over nine million Veterans enrolled, VA’s the largest integrated healthcare system in America. We employ 23,000 doctors and 91,000 nurses—the largest employer of nurses in the country. These professionals deliver everything from primary care to complex specialized procedures like organ transplants and neurosurgery.

We train 120,000 healthcare professionals a year: 62,000 medical students and residents, 23,000 nursing students, 33,000 students in other health fields. An estimated 70 percent of all U.S. doctors have trained with VA, and we’re affiliated with over 1,800 educational institutions.

And we manage a budget of $169 billion.

If VA were in the private sector, it would be a Fortune 10 company.

And transforming an organization of that size and complexity in the private sector would be a massive, long-term undertaking.

Now, think about getting it done in the federal government.

VA has 535 board members, otherwise known as Congress.

Sixty-five percent of our 350,000 employees are unionized.

Hiring is hard. Firing is harder.

And budget and acquisition processes are onerous and inflexible.

So we still have work to do.

But you expect progress. So, I want to talk about progress and about change. And I’ll begin with the question everyone seems to ask: Who’s been fired?

Folks are correct—there’s no way to change the culture unless we hold people accountable for misconduct or management negligence.

Nearly 1,800 employees have been terminated since Bob [McDonald] arrived—compared to just over 1,000 in all of fiscal 2014.

Disciplinary action have been proposed for 187 employees for access-related failures.

We proposed removal of six senior executives—four were removed, two retired.

None of the senior people in the chain of responsibility in 2010 and 2011 when Denver construction went off the rails are still at VA.

And if you’re going to effect change, you often have to change leaders.

Of VA’s top 17 leaders, 13 are new. I’ve been at VA for 18 months, and I’ve got the longest tenure of those 13.

Now, I’ve got to tell you, in all my years of experience in the private sector, I never encountered any organization where the measure of leadership and management excellence was based on how many people you fired.

What matters the most for VA or any large organization is the kind of sustainable accountability that shapes customer outcomes—in this case, Veteran outcomes—not just today, but over the long term.

Sustainable accountability is making sure employees understand our mission, values, and strategy—rewarding good work and calling poor performance to account. And it’s meaningful performance goals and the resources and tools to meet those goals.

Here’s an example of sustainable accountability in action.

We have a tool called Strategic Analytics for Improvement and Learning (SAIL). SAIL measures and reports the care quality, patient safety, and other care metrics for all of our medical centers. It’s VA’s healthcare report card, our roadmap for improving healthcare for Veterans by assessing things like mortality rates, inpatient length of stay, hospital acquired infections, customer satisfaction, and access.

Most healthcare industry report cards are updated annually.

SAIL is updated quarterly and includes many hyperlinks to reports and improvement tools for individual metrics—such as in-hospital complications—that are updated on monthly, bi-weekly or even a daily basis so our leaders and staff can track and improve performance in a timely manner.

SAIL’s one of the most heavily used reports in the VA system. The number of users has doubled over the last year to more than 13,000. And this fiscal year, for the first time, delivering Veteran healthcare outcomes as measured in SAIL is included in every medical center directors’ performance evaluation.

How good is SAIL? The chief medical officer of one of the largest healthcare organizations in America told me that if he had SAIL in his organization, he’d implement it tomorrow.

Is it making a difference? Sixty-one percent of VA medical centers improved quality of care over the past 12 months—improvements in key measures of patient care like mortality rates, length of stay, ambulatory care sensitive condition hospitalizations, and re-admissions for congestive heart failure.

Did you know that Veterans have a lower risk of dying of heart failure in their VA hospital than in the private sector? Did you know that VA exceeds private and public-sector hospitals in prescribing Beta-Blockers after a heart attack, controlling high blood pressure, and conducting colorectal cancer screening?

VA hospitals match or are better than the best private sector healthcare systems for patient safety and preventing hospital-acquired infections. For example, since 2006, central line associated bloodstream infections are down 80 percent, ventilator associated pneumonia are down 90 percent, and methicillin-resistant Staphylococcus aureus—MRSA—are down 80 percent.

How good’s that? Here’s how Tina Rosenberg explains it in a January New York Times article:

Hospital-acquired infection is one of the country’s leading causes of death, killing 75,000 people per year—more than car accidents and breast cancer combined. . . . [H]ospitals have only started to take prevention seriously in the last decade, most in the last five years. . . . One hospital group, however, has done more than all others. It’s not the Mayo Clinic’s hospitals, nor the Cleveland Clinic’s, nor Kaiser Permanente, nor Sutter, nor Geisinger. . . . all hospital chains known for their quality, but another big name leaves them in the dust: the V.A. . . . VA’s achievement is even more remarkable because its patients are older and sicker than patients in other hospitals.

Not only does VA care compare favorably in many categories of patient outcomes, most Veterans are satisfied with their VA care.

First, tell me of another major part of the federal government that has transformed more in the last three years than VBA. Three years ago they were moving 5,000 tons of paper every year to process Veteran claims. Now, all that processing is digital, which has enabled a major improvement in service to Veterans.

Since the 2013 peak of 611,000, backlogged claims have been reduced by 83 percent—it’s the lowest since we started keeping track in 2007. The claims inventory is the lowest since 2008—and productivity has risen by 67 percent since 2009.

Remember, backlog claims are those over 125 days. Average days pending right now is down to 107.

They completed a record-breaking 1.17 million claims in 2013. In 2014, they beat that with another record year—1.32 million claims. And they accomplished all that while increasing claim-level accuracy from 83 percent in 2011 to 91 percent today and bringing the issue-level accuracy to 96 percent.

This is real progress.

But we still have Veterans waiting too long, so we have more work to do.

Let’s talk about improving access to care. A little over a year ago, we had 300,000 appointments that couldn’t be completed within 30 days of when the Veteran needed or wanted to be seen.

Question: How much capacity would we have to create in our healthcare system to be able to timely meet that additional demand? Simple logic says that if we could complete 300,000 more appointments each month, or about 3.5 million annually, we should be able to absorb that demand.

How did we do? Over the last year, we completed seven million more appointments both inside VA and in the community.

We expanded capacity by focusing on staffing, space, productivity, and VA Community Care.

Over the last year our net VHA staffing is up 12,000, including 1,000 more physicians, 2,700 more nurses.

We activated over 1.7 million square feet last year, and we’re more productive—clinical output increased 8 percent. We’re identifying unused capacity, optimizing scheduling, heading off “no-shows” and late appointment cancellations, and extending clinic hours at night and on weekends—the 1.5 million encounters during extended hours was a 10 percent increase.

And we’re aggressively using care in the community. One-and-a-half million Veterans were authorized care in the community in the last year—a 36 percent increase.

Notwithstanding the increase, VA Community Care has been confusing to Veterans, community providers, and staff so, we’re developing a plan to submit to Congress that consolidates and simplifies all our care-in-the-community programs.

With all that progress in improving access, how are we doing on wait times? We complete 97 percent of appointments within 30 days, but we know, in many instances, a Veteran may need to be seen sooner than that. We complete 92 percent within 14 days, 88 percent within seven days, and 22 percent same day.

Average wait times? Five days for specialty care, four days for primary care, and three days for mental health.

What happened to appointments over 30 days? They’ve gone up by 50 percent to about 450,000.

How could that be?

We completed 7 million more appointments.

What we have come to understand is that as we improve access, more Veterans are coming to VA for more of their care. As all of you know, Veterans want to come to VA for care either because of personal preference or economic advantage. Keep in mind, that 81 percent of Veterans receiving care at VA have either Medicare, Medicaid, Tricare, or private insurance. Often they want to come to VA because the out-of-pocket cost is lower.

So, we have more work to do.

So, I mentioned transformation at the outset, bringing VA into the 21st century—an historic, department-wide transformation. We’re changing VA’s culture and making Veterans the center of all we do. We call this transformation MyVA.

I could list out our five MyVA objectives. Instead, imagine what MyVA can mean to America’s Veterans.

Imagine Veterans talking about timely access to great care, customer service that matches anything in the private sector, thoughtful and caring employees, and state-of-the-art technology making it easy for Veterans to use VA services.

Imagine our 350,000 staff directly engaged in improving the customer experience in their own area—a dedicated workforce committed to the mission of serving Americas’ Veterans.

Imagine support services like Human Resources, Information Technology, supply chain, and construction as critical enablers to our frontline staff, all delivered at better value for taxpayers.

Imagine a vital network of collaborative relationships across the federal government, across state and local government, and with both non-profit and for-profit organizations, much like the excellent work you have seen on Veteran homelessness.

That’s where we’re going.

And we need the help of everyone in this room and every VSO, stakeholder, and member of Congress to succeed.

Congress acted recently to give VA limited flexibility to use money appropriated for Veteran care in the community to pay for Veteran care in the community. But that flexibility only lasts until the end of this fiscal year—about 40 more days.

More importantly, they have come to understand that having multiple care-in-the- community programs with different funding sources doesn’t make sense for Veterans, community providers, or VA. We are committed to working together to simplify those programs.

And we need adequate funding and further flexibility to meet the challenges ahead.

If the House cuts the President’s budget request by $1.4 billion, as they proposed, that means $688 million less for Veterans Medical Care—the equivalent of over 70,000 fewer Veterans receiving VA medical care—no funding for four Major Construction projects and six cemetery projects.

All of this—the lack of flexibility, the cuts, discussions about whether Veterans actually deserve a medical system to call their own—leads to a place where the needs of Veterans are secondary to other agendas. It’s unacceptable to VA leadership, and should be unacceptable to anyone claiming to care about our Nation’s Veterans.

I started out with challenges we are tackling. We have one last challenge before us: telling the whole story, making sure Veterans and the American people know the whole story—things VA is doing extraordinarily well, and there are many, as well as those things we must do better.

Now, some here think I mounted a “defense” of VA today.

You’d be mistaken. What you heard—which you rarely hear today—is the “rest of the story”—a more complete picture.

So, we have work to do. With your support—and the support of many others– we will succeed.

Stew Hickey, Larry Via, Sylvia Roland—thank you for the real difference you make for America’s Veterans and the strong collaborative partnership we share in our work together.